Any book has two aspects -- the book as meant by the author, the book as received by readers. The two aspects never fully match, which is perhaps why George Orwell wrote that every book is inevitably a failure. A writer cannot be blamed for the prejudices of his readers, but he is responsible for the logical consequences of his ideas. This book exemplifies this duality.
David Healy has provided trenchant critiques to contemporary psychiatry. Coming from within the profession, by a psychiatrist who himself conducted psychopharmacology research, his critiques have carried some weight. He also has done the hard work of oral history in psychopharmacology, doing for this field what great historians like my friend Paul Roazen did for psychoanalysis (1). Yet, there is no history without interpretation, and Healy's histories, though often well-documented and dispassionately presented, ultimately end in passionate interpretations and prescriptions which are, in the end, one of multiple interpretations. Previously, he had criticized antidepressants, later antipsychotics, and by extension, the psychiatric profession's current views regarding depression and schizophrenia. Now, it is the turn of mood stabilizers, and bipolar disorder, to fall under the Healyan axe.
The book's theses are provided on page 242, with the implication that the preceding 241 pages naturally lead to these conclusions: "Manic-depressive illness provides a compelling symbol of the current problems in medicine. Its dominant therapies are classified under an advertising rubric -- mood stabilization. The core illness has been rebranded in a way that is all but meaningless. The basis on which its leading drugs were patented appears to make a mockery of the patent system, in terms of the goals of both novelty and public utility that the system is supposed to serve." Healy's book only partially supports the above interpretations.
Historians of medicine, often specialists in history but amateurs in medicine, have previously made similar critiques, and the basic themes that underlie Healy's work is taken from that discipline. Ultimately traceable to Foucault, the basic view is that medicine (and science) is not the progressive, simple affair it has seemed, but rather a complex cultural construction. Not only the profession, but the illnesses themselves, are "social constructions." There is either no "real" entity out there that underlies these constructions, or, if there is, such a real entity is not the same thing as the varied cultural constructions that exist over the years. The relevance of social, political, and economic factors for all human activity was insisted upon long before Healy or Foucault; of course, Marx deserves due credit here. (I am not implying that this is good or bad, though perhaps some credit is due to Marx the thinker despite our cultural antagonism to Marxism). This restatement of an old and true proposition still seems to sting, especially in what Healy terms today's American "corporate psychiatry".
This is a book of history, indeed, but it is one with an agenda (as is the case with all history), one that becomes clear in the final chapters (as with Healy's other historical works). In this case, Healy is particularly bothered by the extension of bipolar diagnosis to children, and inappropriate (sometimes fatal) use of psychotropic medications. That is not all there is to his critique, but it seems to be where the passion lies. Yet, unhappiness with the extension of a diagnosis is not itself a criticism of the diagnosis. I have had a dialogue with Healy online about his critique, and he does not deny that there is a real deadly disease, which we may call bipolar or manic-depressive, but he seeks to criticize, as best as I can tell, how we are defining this disease in the last two decades. His view is that we are defining it (wrongly) broadly, primarily under the influence of the pharmaceutical industry.
For readers who want to know the basic format of the 302 page book, of nine chapters, the first provides 23 pages in which views on mania and melancholia are provided from Greek and Roman antiquity and the Middle Ages. The second provides an evolution of views on the brain in the late medieval era; the third describes the French description of cyclic madness, similar to our current views of bipolarity, in the 19th century; the fourth traces the rise of lithium; the fifth the rebirth of the bipolar concept in the 1960s and 70s; the sixth the rise of the anticonvulsants; the seventh the spread of the diagnosis to bipolar children and a spectrum of milder conditions; the eighth the mechanisms of pharmaceutical influence; and the ninth a summarizing jeremiad.
One cannot do justice to both the strengths and the flaws of such a book. The strengths lie in Healy's constant push for us to challenge our preconceived notions, in the informative sections on the development of mood stabilizers, on the historical background on the important psychiatric figures of the 19th and 20th centuries involved with bipolar disorder (the description of the conflict between Michael Shepherd and Mogens Schou is riveting reading), and the economic context in which the pharmaceutical industry influences our profession. I also like his description of the ossification of medical tradition after Galen in a theory-based approach, and have emphasized the Hippocratic alternative (2), which is observation-based and disease-oriented (and in fact consist with the founding notions of evidence-based medicine [EBM], which Healy finds deeply flawed).
The flaws are clinical and historical. Clinically, one finds some logical inconsistencies: for instance, the rise of lithium is seen as an impetus for increased bipolar diagnosis in the 1960s and 1970s, yet Healy does not discuss the sizeable literature from the 1980s and early 1990s arguing for poor lithium response. There are also important scientific omissions: he barely recognizes the extensive literature demonstrating lithium's benefits in prevention of suicide and reduction of mortality—a hard medical outcome that challenges his implication that most psychiatric diagnoses and treatments are conducted on subjective grounds. In his critique of the concept of mood stabilization, Healy cites only one contemporary figure's position, and does not describe the broader and richer scientific discussion of the last decade on that topic, especially the attempt to define the term mood stabilizer based on prophylaxis. Uninformed readers will conclude that all these drugs are merely marketing fictions. Healy the clinician may not mean this; but Healy the writer has not made it clear.
If readers then conclude that lithium is just a marketing fiction, they will have to account for cases such as this one: Recently I consulted on a legal case of a 70 year old man with bipolar disorder who had been completely stable and free of any mood symptoms at all for over three decades (completely cured, while previously he had experienced severe suicidal major depressive episodes that did not even respond to ECT). He and his psychiatrist decided that, after so much wellness, perhaps he did not need lithium. 5 months later, he had a new severe depressive episode and committed suicide. Apparently, the use of a marketing fiction for a meaninglessly-defined entity cured, and its removal killed, this person.
An assumption of inappropriate broadening of bipolar diagnosis also occurs in a selective empirical vacuum: Healy does not cite an extensive under-diagnosis literature in recent years, which persists despite all the broadening of diagnosis in past decades (3). In the absence of empirical proof of mistaken diagnosis, one cannot presume that increased diagnosis represents increased misdiagnosis. AIDS also is diagnosed much more these days than it was in the 1980s.
Historical shortcomings are of special importance, since Healy has developed a niche as a specialized historian of psychopharmacology. We can begin in ancient Greece and Rome. Healy is particularly critical of those who claim origins to bipolar concepts in those eras, a matter which came to the fore in our recent online exchanges (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1518696). He wishes to counteract definitively the assertion that ancient Roman or Greek physicians described anything similar to present-day bipolar disorder. To do this, he focuses on their description of physical signs, as opposed to subjective psychological emotions, and emphasizes their commitment to description of symptoms in the context of the theory of four humours. Yet even with those aspects, it is difficult not to see the mania and melancholia of Hippocrates and Aretaeus as having some similarities to today's mania and depression (even if differential diagnoses have changed, and social construction is granted). These links are not lightly made, but are based on translations from the original Latin made by European bipolar experts themselves (4). Healy's work is based on his own translations from the Greek; he feels that these other authors are selectively misrepresenting sections of the original Hippocratic works. Who is correct here will depend on further scholarship. Even if we grant that something like today's bipolar disorder was never described until mid 19th century France -- which is Healy's view - then we also need to be explicit that pharmaceutical companies were nowhere to be seen. Perhaps he is not arguing that bipolar disorder does not exist, that it is a fiction; rather, he seems to be saying that our current social construction of it is too broad. Nevertheless, I have already had one mental health professional gleefully cite Healy's book in the claim that the disorder is altogether a fiction, created by the pharmaceutical industry. Such readers at least need to provide the name of the company so involved in 1854 Paris.
The discussion of Kraepelin in Healy's book is brief, and in my view, limited. Healy argues that Kraepelin's contribution was mainly in his definition of dementia praecox (DP), and that MDI as just a foil of nonspecific leftovers to DP. In fact, Kraepelin spent a good deal of effort and space in his descriptions of MDI, and he diagnosed and treated many such patients, much more than of DP. This is a matter of fact, not opinion; here are the results of an examination of actual medical records in Kraepelin's Munich clinic (5): In 1908, of 721 patients admitted, the most common diagnosis was alcoholism (n=161), followed by MDI (n=134); dementia praecox was 7th (n=53). Thus Kraepelin diagnosed MDI most frequently among primary psychiatric conditions, and 2.5 times more frequently than dementia praecox. Further, contemporary rediagnosis of those charts demonstrated that 23% of Kraepelin's MDI diagnoses would not meet current bipolar definitions: Krapelin's view of MDI was that it was a broadly diagnosed and common condition. Healy's historical scholarship is simply wrong here. Kraepelin's main interest, clinically and theoretically, was in MDI; DP was not privileged in his thinking at all. And, although posthumous psychological guessing is hazardous, I think Kraepelin likely would have been overjoyed to hear of the concept of a bipolar spectrum, contrary to Healy's claims.
Nowhere does Healy arrive clearly at the core of Kraepelin's concept of MDI, that it was a disease essentially characterized by recurrence, not mania. Indeed, recurrence is the hallmark of the disease, as today's standard text on the topic clearly shows (6), for Kraepelin and many of his followers, not the presence of mania. Healy's book has the wrong target: it seeks to deconstruct mania, thereby to dethrone bipolar disorder. But MDI (the non-French, non-Leonhard, non-DSM III variety; the Kraepelin/Kahlbaum/Falret/Pinel/Aretaeus/Hippocrates variety) is not defined by mania, but rather based on recurrence (7, 8).
The concept of a recurrent mental illness, with highs and lows of mood, activity, and thinking (or mania and depression in current terms) has been around since before the persons who Healy insists were the originators in mid-19th century France and later. At the very least, Pinel described this condition (periodic insanity) as a core mental illness, in the very first pages of his 1806 Treatise on Insanity: "Intermittent or periodical insanity is the most common form of the disease. The symptoms which mark its accessions, correspond with those of continued mania. Its paroxysms are of a determined duration, and it is not difficult to observe their progress, their highest development, and their termination" (9) (p. 5). Pinel goes on to develop his moral treatment specifically for this disease, which has all the appearances of MDI (peace to social constructionists). Healy has recently translated Pinel's treatise from the French, and perhaps not surprisingly, draws the opposite interpretation about bipolar disorder. But as Healy himself admits, periodicity of abnormal behavior of the insane was clearly there in Pinel. The only question is whether we wish to diagnose this condition broadly, as Kraepelin did, as a recurrent disorder of mood, thought, and behavior -- and indeed as advocates of the bipolar spectrum do -- or whether we want to divide it up into many conditions (unipolar, bipolar, anxiety disorders).
Healy makes a great deal of how he believes Kraepelin would have been bothered by current "neo-Kraepelinian" efforts to revise and expand the bipolar concept in his name, even though Kraepelin's own MDI concept allowed for mixed-states, mild illnesses, and even conditions approaching modern personality disorders, as well as mania and melacholia. A number of times, Healy identifies the modern targets of his critique as coming from "Boston," as if medical and academic leaders of the city held a special influence in the US. There was a time when Boston was viewed as the American Athens, and when it could be dubbed the Hub of the Solar-System. These days, it likely cannot claim such undue influence; nonetheless, as its once and current denizen, I may be justified then in drafting a response: Healy errs exactly because he has not comprehended the centrality of recurrence for Kraepelin's notion of MDI. Current views of a broad bipolar "spectrum" are not so much new (and surely do not emanate from Boston) as indeed a return to Kraepelin, precisely because in 1980, the APA's DSM-III moved away from Kraepelin (as well as from Kalhbaum and Pinel and his successors Esquirol, Baillarger and Falret, father and son), and towards the mid 19th-century French concept of bipolar disorder. DSM-III was in fact Kraepelinian about schizophrenia (DP) but non-Kraepelinian about bipolar disorder (there it took Leonhard's approach, which Healy describes but the relevance of which he has not apparently appreciated, for post-1980 concepts of bipolar disorder).
Thus, his view on Kraepelin, the key figure in this story, is, in my opinion, mistaken; he does not seem to realize that the DSM-III, Leonhardian, and mid-19th century French version of bipolar disorder, in which the polarity of narrowly defined mania are the core diagnostic features, is a very different concept than the Kraepelin nosology of MDI, where polarity matters little (most episodes are mixed and thus polarity cannot even be established in this view and that of his associate Weygandt (10)), and where recurrence and periodicity is the hallmark of the illness. Current bipolar spectrum concepts are essentially trying to go behind DSM-III in history, back to the Kraepelinian, as opposed to the Leonhardian, paradigm, and thus not only would "co-opting the Kraepleinian brand" to "move psychiatry into a world that Kraepelin would not recognize." As a historical matter, Kraepelin's charts and his diagnostic practice is quite the opposite of the DSM-III bipolar conception, and the spectrum concepts are indeed similar to Kraepelin's documented clinical world.
Another Healyan reproach to contemporary psychiatry is that the current view of mania and bipolar disorder is being broadened beyond the "core" condition unjustly. This critique is tautological: he defines the core condition narrowly, following the current mainstream DSM-III based view (following Leonhard and in line with pre-Kraepelinian notions in mid 19th century France); thus of course he would find few cases of a narrowly defined disease (as he shows based on late 19th century records in Wales assessed using these criteria). But this critique begs the question, for it does not invalidate a broad view of mania: it merely shows that assessed narrowly, the condition is infrequent, and assessed broadly, it is frequent. Which approach is valid is not addressed. Healy and others (like German Berrios, whom he cites) may oppose broad use of the terms mania or bipolar disorder, but this is itself an opinion, one among others. It is for clinical research to define the merits and flaws of the narrow versus broad interpretations, and that research, thus far, in my interpretation, has shown a number of merits to the broad view (such as some supportive genetic studies, its utility in clinical practice, an evidence base of support in course and treatment response studies), as well as some weaknesses (including lack of consensus on its definition and boundaries) (11, 12). Healy has assumed the weaknesses without giving much attention to the merits.
All the previous discussion is important clinically; it should matter to clinicians and to patients because it involves practical judgments about diagnosis and treatment.
But perhaps the most important matter to discuss in relation to this book is its underlying philosophy. It is a postmodernist interpretation of psychiatry, through and through. This is not to imply that Healy has read and studied Foucault or postmodern theory; it is to say that our culture is infected with these ideas, and this book is a symptom of that condition. Karl Jaspers taught that we always ascribe to a philosophy, consciously or unconsciously. A critique of any book needs to also try to see what its underlying conceptual assumptions are, and then to see if these assumptions are valid.
All this talk of "disease-mongering," for instance, may perhaps be itself a symptom of a disease: the postmodernist disease. This is an affliction in which one thinks there is no such thing as Truth, or even truths; that all ideas are opinions, each more or less relativistically valid, or, perhaps (following Foucault) valid only in the context of "discourses" (cultural contexts) driven by power relations (wealth, social class). This is the world of Foucault and it has seeped into our culture, so that many of us in the Western world have imbibed these dogmas in our bones.
This is not to say that Healy does not believe that there is such a thing as truth, but his historical analysis logically heads in that direction, and he never explicitly shows when and where his views would differ from such postmodernist conclusions. If Healy believes that bipolar disorder is a biological disease, and not purely or even mostly cultural in origin, then he should be explicit about it. And not just once or twice, but throughout his analysis. When he deconstructs bipolar disorder almost into nothingness, the question can be asked whether there is any practical difference between making the condition rare and narrowly defined versus simply viewing it as a fiction, a cultural artifact. If we replace biological with cultural reductionism, have we done anything meaningful?
The postmodernist critique is, in great measure, a reaction to the positivistic philosophy of science that dominated the 19th and 20th centuries. Yet the options are not the two extremes of postmodern nihilism or positivistic dogmatism. There are other perspectives, such as Karl Jaspers' pluralism (expanded in the Continental tradition of phenomenology) or William James' pragmatism (expanded later in the works of WVO Quine, Daniel Dennett, and others). There is indeed, dare one use the word, a spectrum; and like all debates, the partisans at the extremes make the most noise.
Daniel Dennett recently gave a remarkable lecture titled "Postmodernism and Truth" (13) in which he makes the point that postmodernist professors of literary theory can afford to be relativistic because they never get sued. Doctors do not have this luxury. I have a simple question for adherents to the doctrine that there is no Truth: would they give lithium in toxic trough serum levels of 4.0 mEq/L to a patient? The fact is that, in medicine, we have a deep moral responsibility precisely because there are truths, because we know how to kill as well as help, because indeed (according to the Institute of Medicine) up to 100,000 patients in the US are killed by medical error yearly (not to mention systematic dogmatism) (14). If we can kill, and we can be sued, and we can be held responsible for right and wrong action, then there are truths, and extreme postmodernism is false, or at least, unrealistic. Healy the clinician knows about these realities but Healy the historian is not explicit about them. In fact, by devoting an entire chapter to analogizing the current psychiatric view of bipolar disorder to Stalinism, he is treading onto dangerous territory.
It is not adherence to a single all-pervading dogma that led to totalitarianism, whether of the Nazi or Stalinist variety; it is the absence of any belief, the twisting of all knowledge into cultural manifestations of power; in a word, postmodernism. It is not a belief in a single Truth, but susceptibility to the Big Lie, due to disbelief in any truth, that led to totalitarianism. Perhaps the most insightful thinker who lived through these experiences was George Orwell, whose whole life can be seen as an effort to combat the nihilistic postmodern attitudes that lead to genocide and totalitarianism: "The very notion of objective truth is fading from the world," he lamented. But, "however much you deny the truth, the truth goes on existing, as it were, behind your back..." (15)
Healy, justifiably, will object to implications of nihilism, as he does in his preface. Yet the critique of psychiatry's social constructions itself occurs in a social context, and the critique can be turned back on itself: how much are the critiques of Foucault, Healy and others, themselves, social constructions, the outcomes of a certain attitude that impacts one's interpretation of history? In the case of non-psychiatrist historians, there is often an anti-psychiatry and anti-medical attitude that wishes to rid us, once and for all, for all that is psychobiology and psychopharmacology. Healy cannot be brushed with that tar, but a certain therapeutic skepticism is unmistakable. Not that this attitude is, in itself, problematic, and I may well share it. However, as William Osler (himself accused of therapeutic nihilism) pointed out long ago, there are two types of skepticism: one is passive, the other active. Passive skepticism degenerates into nihilism: nothing works; nothing is helpful; everything we try to do makes things worse, or at best is ineffectual. Active skepticism is the scientific attitude, according to Osler, an unwillingness to accept the status quo simply because of its pre-existence, but also an active search for solid ground, as solid as we can get, knowing that no ground is absolute, and that our knowledge is an island surrounded by doubt and uncertainty: "not the passive skepticism born of despair, but the active skepticism born of a knowledge that recognizes its limitations..." (16) (p. 239) This recognition of the limits of our certainty need not degenerate into postmodern extremism, however, and by being active in search for what we can know with a high degree of plausibility, this approach serves to generate useful and perhaps "true" knowledge, rather than forever being engaged in negative criticism. Negative criticism may be enough in literary theory, but medical practice needs to know what to do, as well as what not to do. Again, Healy the clinician likely knows this, but Healy the historian never acknowledges this limitation to his deconstructive labors. Once more, uninformed clinicians, and worse yet, a confused public, will draw mistaken conclusions.
I will also engage in Healy's passion about pediatric bipolar disorder, the concern that children are being wrongfully killed with excessive medications for a mistaken diagnosis. These two aspects need to be separated; I can agree with the one without accepting the other: Many children with bipolar disorder are underdiagnosed, and misdiagnosed with other conditions, both empirically supported statements; many are probably overtreated with medications, irrespective of their bipolar diagnosis (many with ADHD and unipolar depression are also overtreated). One could hold, as I do, that we should diagnose bipolar disorder more frequently in children, but treat them with fewer, and more effective, medications (1). Nowhere in this book is there any mention, not to mention analysis, of the epidemic avoidance of the MDI diagnosis, for most of the 20th century, in favor of overdiagnosed schizophrenia and "depression", facts that have been well-established for decades (17). So it is a reasonable interpretation of the full, and not partial, history of MDI to conclude that perhaps as many, likely more, adults have died from undiagnosed and untreated MDI than children have died from misdiagnosed and overtreated bipolar disorder.
Reviews are always failures too, because there will be a distance between what I meant to say, and what readers will conclude. This review is not meant to say that everything is just fine in contemporary psychiatry; I am not defending the academic establishment or the pharmaceutical industry. They are both worthy of much criticism. Much of what passes for science today is junk science, which should appropriately be deconstructed away. But when the oldest and most biological psychiatric condition equally disappears along with the newest ADHD fad, then postmodern methods become dogmas, and truths are sacrificed on the altar of postmodernist unbelief. Contemporary psychiatry and science is a mess in many ways. But the opposite of falsehood is not truth. A partial critique, though bringing out important matters, is not completely valid; if this review highlights its weaknesses, it does not follow that the psychiatric status quo is acceptable, a topic which I have philosophically explored in detail elsewhere (11).
The length and effort put into this review is a reflection of my respect for the work. David Healy is an active clinician and historian, an uncommon combination, and it is no easy feat to research and write a book like this one. I and others have put similar efforts into understanding bipolar disorder, in my case clinically and philosophically. We all share a similar aim, I believe -- the old-school goal of wanting to know the truth. Hopefully, future work will be more two-sided and complete, and then perhaps all our efforts will become synergistic, clarifying this complex field, rather than adding to centuries of confusion.
In the end, as with any book, whatever the author meant, readers' interpretations will matter most. Some will benefit greatly from this book, seeing its limitations and learning from its insights. Others will cling to the book to justify their postmodern nihilism, even perhaps against the author's wishes. They will say, incorrectly, that there is no bipolar disorder; it is a fiction. Or, if it is real, it is rare, they will demand, also incorrectly. But the Truth will go on existing behind their backs, and whether we like it or not, this recurrent mental condition will still -- and not infrequently -- continue to make its deadly presence known.
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17. Pope HG, Jr., Lipinski JF, Jr.: Diagnosis in schizophrenia and manic-depressive illness: a reassessment of the specificity of 'schizophrenic' symptoms in the light of current research. Arch Gen Psychiatry 1978; 35(7):811-28
© 2008 Nassir Ghaemi
S. Nassir Ghaemi, M.D., M.A., M.P.H., Director, Mood Disorders Program, Tufts Medical Center, Dept of Psychiatry. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.